I knew it was going to happen...
The health care reform debate has finally got around to blaming fat people for the nation's health problems.
I've been avoiding thinking about this and writing about this because, well, it's tiresome. This is something that I see so clearly and it is obvious that the majority of Americans (and really the rest of the western world, or at least, English speaking world) just can't see. I hate the disconnect. I feel like I've seen and I've written clear and concise arguments over and over again only to have the exact same questions asked and the exact same rebuttals made. These questions and rebuttals are phrased in such a way that it is obvious the person posing them has not heard/read and/or understood a word on the clear and concise argument.
Ever spent time with a three-year-old who has discovered the word "why"? You speak and the response, no matter what you say, is "Why? Why? Why?Why? Why? Why?Why? Why? Why?Why? Why? Why?Why? Why? Why?" By the end of the "conversation" you are thinking "Why do I bother?"
Or in the words of Mugatu (Will Ferrell) in Zoolander: "I feel like I'm taking crazy pills."
So with this extremely impatient introduction let me make an argument for why the last thing health care reform needs to do is try to make people lose weight and why Health at Every Size (HAES) is the best preventative care option for containing health care costs AND making our country healthier.
TOP 7 REASONS FOR
MAKING HAES THE ONLY PUBLIC HEALTH POLICY ON WEIGHT
7. Almost every method for losing weight ends in weight gain.
There is no viable way for taking weight off and keeping it off for the vast majority of people. In fact, there is ample evidence (pun intended) that dieting and weight loss schemes may be one of the reasons that Americans are larger than they were 20 years ago.
6. Almost every method for losing weight has led to dire health consequences in long-term health outcomes.
Most weight loss schemes, including so called "sensible" ones often lead to poorer health outcomes for individuals who temporarily succeed at them. Drugs are often pulled off the market within a few years of introduction due to disability and death caused by them. WLS has some of the highest mortality and comorbidity rates of any surgery done on a regular basis. Severe calorie restrictions and various appetite suppression schemes cause all sorts of short-term and long-term health problems. Not only is there no proven way to lose weight permanently, there is no proven safe way to lose weight.
5. There is precious little evidence that being fat CAUSES any disease
Yes, there are correlations. But there are correlations between being male and certain diseases and no one is advocating castration for cures. There are correlations between being of African descent and certain diseases and no one is advocating skin lightening as curative. Three conditions must exist to show cause and effect:
First, the cause has to take place in time before the effect. Since figuring out when a disease started (diagnosis is always after the start of a disease), it is often impossible to know which came first, the weight gain or the disease.
Second, a change in the cause should produce a change in the effect. This correlation has been established on a population level. We have gotten fatter over the same period of time that we have, as a group, experienced more heart disease, diabetes, high blood pressure and so forth. But establishing the population correlation isn't the same as establishing individual correlations. For example, little evidence exists that losing weight in a particular individual leads to a change in their health conditions, especially when we consider the third condition to establish cause and effect.
Finally, NO OTHER EXPLANATION has to be available to explain the relationship between the cause and effect. So, in the case of weight loss, since most people trying to lose weight often change diet and/or their physical activity, the actual change in eating and/or exercise may be the more plausible explanation for changes in health associated with weight loss. Since precious few have actually studied or questioned the "cause and effect" aspects of weight with any kind of rigor, at this point we do not really know what the relationship between weight and disease are. We only know that over the past 30 years, people have gained weight and prevalence of certain health conditions have increased. We are far from establishing cause and effect and this is true no matter how many times people get on TV and say "obesity causes..."
4. We know that stigmatization contributes to ill health.
Any "program" that promotes weight loss is stigmatizing fat people. I know that is a radical thing to say, but it is true. Weight loss as a goal means getting rid of fat and it requires a demonization of fat in order to make it a goal. Fat carries stigma in this culture. Weight loss reinforces that stigma. Any public health policy that makes weight loss an overall PUBLIC goal is going to perpetuate stigma. That means even with accessibility, fat people will not receive the proper care they deserve either because some medical professional is going to concentrate on weight loss instead of the health condition OR many fat people, having been shamed or unwelcomed in medical settings is going to put off going to see a health care professional until it is too late. Thus, continuing to stigmatize fat is going to lead to worse health outcomes, not better ones.
3. We do know that exercise has a beneficial effect on individual health no matter what their size.
Health at Every Size promotes the idea that we should be pursuing health NOT weight loss. So here's where I know that the proponents of obesity as health crisis do not really care about the health of fat people and do NOT believe their own assertions about how to lose weight. Most HAES professionals advocate that to become healthy, all individuals should eat well-balanced foods with good macro and micro nutrients and should move their bodies more. Most weight-loss gurus recommend pretty much the same thing -- changes in eating and exercise to achieve weight loss. SO, if the weight-loss gurus believe that these lifestyle changes will lead to weight loss because of the physics of calorie consumption and conduction, why are they worried about HAES? If they are correct and we encourage persons of all sizes to eat well and exercise regularly, then fat people would lose weight, right? Does it actually require the fat persons active measurement of weight to lose the weight? No. If they are right, the weight would go down whether the person is weighing themselves or not. So if I were truly wanting to promote weight loss and I heard that a bunch of fat people were willing to exercise and improve their diets, wouldn't I be happy to just let them do it? Wouldn't I be elated that they got the message? But the opposite is true. Weight-loss gurus are threatened by the HAES movement. I believe that is because most of these people who say they are concerned about the health of bigger people have no such concern. What they want is more money, more prestige and more power for themselves. HAES as a health policy concentrates on providing encouragement for persons of ALL SIZES to take good care of their bodies. Fat acceptance means no more stigma of fat persons, which means that a fat neutral world would encourage healthier lifestyle practices.
2. HAES would mean better health for thin people too
By concentrating on weight rather than health, especially in children, the health habits of many so called "normal" weight and "underweight" persons are ignored. Since size = health indicator is so prevalent, the naturally thin persons often believe they are okay eating what they eat and not exercising. By paying attention to behavior instead of a physical characteristic, all persons will be encouraged to pursue healthier lives.
1. HAES will work to improve health where weight loss will not
There has been one study done in all the years of weight research that actually asks this question about success. Linda Bacon did a 2 year study running two groups, one that dieted and one that practiced HAES. The results were what any chronic dieter could tell you. Those who concentrated on losing weight were in poorer health at the end of the two years. Those who concentrated on improving health regardless of weight, were healthier. One study does not make a conclusive case, of course, but it certainly supports the need for further study and promises hope where most weight loss studies do not.
REAL PREVENTATIVE HEALTH CARE
The question of health care reform is a complex one and I agree that preventative health needs to be a part of the equation to cut costs and to ensure success. Our current system only encourages the financial health of a few at the expense of the rest of us. WEIGHT CANNOT be the ONLY consideration in this debate. In fact, so called "lifestyle" changes, cannot be the only consideration. In addition to a lack of access to health care, factors such as poverty, pollution, violence, food safety, drug safety, health care provider competence, effective vaccinations and stigmatization are just a few of the other things that need to be a part of this debate. HAES could be a key policy that would promote the end of stigmatization on the basis of size and the encouragement of a strong and healthy population. Weight loss, however, will be doomed to failure and in the end will add more costs rather than saving us.
If we want to succeed in creating true health care reform, we need to acknowledge and act upon fact, not fiction. Weight loss as a method of health improvement is a fiction, an often repeated fiction, but a fiction nonetheless. I feel compelled to repeat a quote that I closed with a few entries ago:
An error does not become truth by reason of multiplied propagation, nor does truth become error because nobody sees it. --Mohandas Gandhi
But I will add this quote as well:
The fact that an opinion has been widely held is no evidence whatever that it is not utterly absurd; indeed in view of the silliness of the majority of mankind, a widespread belief is more likely to be foolish than sensible. -- Bertrand Russell